Everything You Need to Know About HEDIS Audits

Buckle up, it’s almost HEDIS season; that time of year when charts are flying and deadlines are looming. For many, it feels like a rollercoaster of data pulls, documentation reviews and compliance checks. But for HIM teams, you’re not just along for the ride—you’re in the control booth, keeping the entire operation on track.

What exactly is HEDIS? HEDIS stands for the Healthcare Effectiveness Data and Information Set, a standardized set of performance measures developed by the National Committee for Quality Assurance (NCQA). HEDIS audits are one of the most important tools in healthcare for measuring provider performance and patient care quality, and HIM leaders are essential to getting this data right.

In this blog post, we will walk you through the process of how HEDIS audits work, from data collection to final reporting, and discuss some of the challenges healthcare organizations commonly face to complete them.

What is a HEDIS Audit?

At its core, HEDIS is a systematic process that measures healthcare quality using patients’ medical records. While claims data gives us part of the picture, actual chart reviews dig deeper, verifying whether the care provided aligns with established quality benchmarks.

HEDIS was created by the NCQA in the early 1990s to provide a standardized way to measure the effectiveness of care across health plans. What started as a tool for large employers to evaluate health plan performance has evolved into a cornerstone of quality measurement in U.S. healthcare.

So, why put  so much emphasis on HEDIS reviews? Because these reviews are directly tied to:

• Improving patient outcomes by identifying care gaps
• Enhancing care delivery through performance feedback loops
• Ensuring regulatory and accreditation compliance with NCQA and CMS
• Supporting value-based care models that reward quality over volume

The reviews themselves focus on specific HEDIS measures, which span key categories like:

• Preventive care: Immunizations, breast cancer screenings, wellness visits, etc.
• Chronic condition management: Tracking and managing chronic conditions like diabetes, hypertension and asthma
• Behavioral health: Including follow-ups after mental health hospitalizations and treatment adherence
• Access to care: Evaluating how easily patients can obtain needed services

For HIM professionals, this process is far more than a data pull. It requires accurate documentation, thorough knowledge of medical records access and a deep understanding of how health data can measure care quality on a major scale.

The HEDIS Audit Process

While HEDIS audits might feel like a whirlwind when we’re in the thick of it, the process itself follows a clear, structured path.

Here’s a breakdown of the key steps:

1. Collecting data: The process begins by gathering both administrative data (like claims and encounter records) and clinical data from patient medical records. While administrative data provides a high-level overview, medical record data fills in the clinical detail many HEDIS measures require.
2. Identifying patient charts: Health plans or third-party vendors generate sample patient populations for each measure. These are the charts that will be reviewed to validate whether the care provided meets the criteria for specific HEDIS measures.
3. Extracting relevant data: HIM teams play a critical role in reviewing selected charts and extracting documentation that confirms compliance with HEDIS criteria—such as blood pressure readings, lab results, immunization records or evidence of follow-up care.
4. Reporting and quality assurance: Once abstraction is complete, data is submitted through validated systems. But it doesn’t stop there—quality assurance checks are conducted to ensure the accuracy, completeness and consistency of the data submitted. Any discrepancies can impact plan ratings and regulatory reporting.

Manual vs. Automated Reviews

Traditionally, HEDIS reviews were highly manual—think spreadsheets, faxed records and a lot of human effort. Today, many organizations are turning to tech-enabled solutions that leverage application programming interfaces (APIs) to pull massive amounts data at once, seemingly automagically. While automation can increase efficiency and reduce human error, it’s still essential to maintain oversight into any process that involves APIs to pull data.

In another post on the HealthMark blog, we discuss the important role an information gatekeeper plays to ensure that only data within the scope of the audit is pulled and interpreted accurately, and that final submissions meet the appropriate standards.

How Often Are HEDIS Audits Done?

HEDIS audits occur on a yearly performance reporting cycle, aligning with the NCQA’s calendar and submission deadlines. While quality and risk scores are a year-round concern, the official review season is concentrated in the first half of the year.

The timeline looks like:

• January-May is for data collection: During the first few months of the year, HIM and quality teams are hard at work gathering administrative and medical record data.
• June is the submission deadline: All HEDIS data must be submitted to the NCQA by the end of June. This includes not just raw data, but also validation documentation and audit materials.

The Challenges of In-House HEDIS Audits

While handling HEDIS audits in-house may seem manageable at first glance (even smaller audits add up!), many HIM leaders quickly realize just how resource-intensive and complex the process can be.

Resource-Intensive Operations

Between training staff, managing shifting priorities and juggling regular HIM responsibilities, audits often stretch internal teams to their limits. Adding to the challenge is the sheer volume of patient records that must be reviewed—each requires an amount of scrutiny and levels of quality control to ensure compliance with HEDIS measures.

Data Accuracy and Security

Manual and automated abstraction and data entry come with inherent risks. A simple oversight or misunderstanding the information in the patient record can lead to inaccurate reporting, missed compliance targets or audit flags. HIM teams must also remain vigilant about data privacy, as it’s not uncommon for information to be pulled that exceeds the scope of the audit.

Should I Outsource HEDIS Audits?

If you’ve ever found yourself buried in chart pulls while juggling a million other HIM responsibilities, you’re not alone. That’s why more organizations are asking the same question: Should we outsource HEDIS audits? While we can’t make that decision for you, we can let you know the feedback we’ve received from healthcare organizations that have made the switch from in-house to outsourcing.

• Reduced administrative burden: Outsourcing takes the time-consuming legwork off your team’s plate. Instead of staff scrambling to meet audit deadlines, they can focus on what really matters.
• Accuracy and compliance: Certified release of information specialists know exactly what auditors are looking for. That means clean, complete and compliant chart reviews that reduce the risk of errors and keep you aligned with HIPAA and NCQA standards.
• Time and cost efficiency: Let’s be honest—rework is expensive. With experts handling the process from the start, you get faster turnaround times, fewer mistakes and a better return on investment compared to staffing up or diverting internal resources.
• Scalable solutions: Whether you’re managing a single clinic or a large, multi-site health system, outsourcing partners can flex their support to match your volume and complexity.
• Dedicated support: You’re never flying solo. With a dedicated account manager guiding you through the audit cycle, you get a true partner in the process—not just a vendor, but a team that feels like an extension of yours.

Weighing Your Options? Let’s Chat

Let’s face it—HEDIS season hits HIM teams hard, and trying to juggle audits on top of your everyday HIM responsibilities can feel like a game of whack-a-mole. That’s why so many healthcare organizations are choosing to outsource their HEDIS audit support to specialized release of information partners.

And no, outsourcing doesn’t mean handing over the reins. It means bringing in a team of trained professionals (or in HealthMark’s case, certified release of information specialists) who live and breathe audits, so your staff can stay focused on what they do best; supporting patient care, staying ahead of compliance and managing health information workflows.

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